Optimal nutrition in lactating women and its effect on later health of offspring: A systematic review of current evidence and recommendations (EarlyNutrition project)

Figures & data

Table 1. Sources searched.

Cochrane Database of Systematic Reviews (CDSR) http://www.thecochranelibrary.com/

Database of Abstracts of Reviews of Effects (DARE) http://www.crd.york.ac.uk/crdweb/

PROSPERO: international prospective register of systematic reviews http://144.32.150.25/PROSPERO/

Health Technology Assessment (HTA) Database http://www.crd.york.ac.uk/crdweb/ [or as part of The Cochrane Library]

SIGN Guidelines http://www.sign.ac.uk/

National Guideline Clearinghouse http://www.guidelines.gov/

National Coordinating Centre for Health Technology Assessment http://www.hta.ac.uk/

NICE Guidelines http://www.nice.org.uk/

Health Services/Technology Assessment Texts (HSTAT) http://www.ncbi.nlm.nih.gov/books/NBK16710/

TRIP http://www.tripdatabase.com

Clinical Evidence http://clinicalevidence.bmj.com/ceweb/conditions/index.jsp

NHS Evidence http://www.evidence.nhs.uk/default.aspx

NHS Clinical Knowledge Summaries (formerly PRODIGY) http://www.cks.nhs.uk/home

Health Systems Evidence: a continuously updated repository of syntheses of research evidence about governance, financial and delivery arrangements within health systems, and about implementation strategies that can support change in health systems http://www.healthsystemsevidence.org/

HSRProj Information about ongoing health services research and public health projects from National Library of Medicine http://wwwcf.nlm.nih.gov/hsr_project/home_proj.cfm

Websites of relevant professional bodies and associations that may have produced guidelines:

• European Society of Paediatric Hepatology, Gastroenterology and Nutrition (ESPGHAN) http://www.espghan.med.up.pt/

• North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) http://www.naspghan.org

• American Academy of Pediatrics, http://www.aap.org/

• World Health Organization, http://www.who.int/publications/guidelines/en/index.html

• Institute of Medicine, http://www.iom.edu/

• Scientific Committee on Nutrition, http://www.sacn.gov.uk/

• EFSA, http://www.efsa.europa.eu/en/publications.htm

• Guidelines International Network, http://www.g-i-n.net

• Deutsche Adipositas Gesellschaft, http://www.adipositas-gesellschaft.de/

• Association for the Study of Obesity, http://www.aso.org.uk/

• World Obesity Federation, http://www.worldobesity.org/

• European Association for the Study of Obesity, http://easo.org/

• European Association for the Study of Diabetes, http://www.easd.org/

• Deutsche Diabetes Gesellschaft, www.deutsche-diabetes-gesellschaft.de

• Verband der Diabetes-Beratungs- und Schulungsberufe in Deutschland e.V., https://www.vdbd.de/index.php

• International Diabetes Federation, http://www.idf.org/

• Deutsche Gesellschaft für Endokrinologie, http://www.endokrinologie.net/

• Schweizerische Gesellschaft für Endokrinologie und Diabetologie, http://www.asemo.ch/

• Society for Endocrinology, http://www.endocrinology.org/index.aspx

• Canadian Society of Endocrinology and Metabolism, http://www.endo-metab.ca/

• European Society of Endocrinology, http://www.ese-hormones.org/

• Endocrine Society, http://www.endocrine.org/

• Deutsche Gesellschaft für Epidemiologie, http://www.dgepi.de/

• International Society for Developmental Originas of Health and Disease, http://www.mrc-leu.soton.ac.uk/dohad/index.asp

• International Epidemiological Association, http://ieaweb.org/

• International Genetic Epidemiology Society, http://www.geneticepi.org/

• Deutsche Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten, http://www.dgvs.de/

• Österreichische Gesellschaft für Gastroenterologie und Hepatologie, http://www.oeggh.at/

• Schweizerische Gesellschaft für Gastroenterologie, http://www.sggssg.ch/home.html

• United European Gastroenterology, https://www.ueg.eu/

• World Gastroenterology Organisation, http://www.worldgastroenterology.org/

• Bundesverband Deutscher Ernährungsmediziner e.V., http://bdem.de/

• Deutsche Gesellschaft für Ernährung, https://www.dge.de/

• Deutsche Gesellschaft für Ernährungsmedizin e. V., http://dgem.de/

• Berufsverband der Oecotrophologie e.V., http://www.vdoe.de/

• Verband der Diätassistenten e.V., http://www.vdd.de/

• American Society for Nutrition, http://www.nutrition.org/

• Parenteral and Enteral Nutrition Society of Asia, http://www.pensa-online.org/index.php

• European Society for Clinical Nutrition and Metabolism, http://www.espen.org/

• European Federation of the Associations of Dietitians, http://www.efad.org

• International Union of Nutritional Sciences, http://www.iuns.org/

• Berufsverband Kinder- und Jugendärzte e.V., http://www.bvkj.de/

• Deutsche Gesellschaft für Kinder- und Jugendmedizin e.V., http://www.dgkj.de/

• Gesellschaft für Pädiatrische Gastroenterologie und Ernährung e.V., http://www.gpge.de/index.html

• Österreichische Gesellschaft für Kinder- und Jugendheilkunde, http://www.docs4you.at/

• Swiss Society of Neonatology, http://www.neonet.ch/en/about-us/aims/

• Pediatric Society in Bosnia and Herzegovina, http://www.upubih.org/

• Paediatric Research Society, http://www.prs.nhs.uk

• Paediatric Society New Zealand, http://www.paediatrics.org.nz/events.asp?pageID=2145870907

• American Pediatric Society together with the Society for Pediatric Research, https://www.aps-spr.org/home.asp

• Canadian Paediatric Society, http://www.cps.ca/en/

• Canadian Neonatal Network, http://www.canadianneonatalnetwork.org/portal/

• Asia Pacific Paediatric Endocrine Society, http://www.appes.org/AboutUs.aspx

• European Society for Paediatric Research, http://www.espr.info/

• European Paediatric Association, http://www.epa-unepsa.org/

• European Society for Neonatology, http://esn.espr.info/

• European Foundation for the Care of Newborn Infants, http://www.efcni.org/

• European Society for Paediatric Endocrinology, http://www.eurospe.org/index.aspx

• Union of European Neonatal & Perinatal Societies, http://www.uenps.com/

• European Academy of Paediatrics, http://www.eapaediatrics.eu/index.ehtml

• Vermont Oxford Network, https://public.vtoxford.org/

• International Confederation of Midwives, http://www.internationalmidwives.org/

Table 2. Medline and Embase search strategy.

1.	LACTATION/
2.	(LACTATION or LACTAT$).ti,ab.
3.	BREAST FEEDING/
4.	(BREAST-FE$ or BREASTFE$).ti,ab.
5.	(BREASTFEED$ or BREAST-FEED$).ti,ab.
6.	(BREAST-MILK or BREASTMILK).ti,ab.
7.	HUMAN MILK/
8.	HUMAN MILK.ti,ab.
9.	(LACTATING MOTHER or LACTATING WOMAN or LACTATING WOMEN).ti,ab.
10.	1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9
11.	(DIET$ or FOOD$ or EAT or EATEN or EATING or NUTRITION$ or FRUIT$ or VEGETABLE$ or NUTRIENT$ or VITAMIN C or THIAMIN or NIACIN or FOLATE$ or MICRONUTRIENT$ or MACRONUTRIENT$ or MULTIVITAMIN$ or FOOD SAFETY or SUPPLEMENT$ or FISH OIL or PROBIOTIC$ or PREBIOTICS$ or FOOD GROUP$ or DIET$ QUALITY or DIET$ PATTERN$ or FOLIC ACID or MAGNESIUM or SELENIUM or ZINC or PYRIDOXINE or RIBOFLAVIN or NICOTINIC ACID or DIETARY SALT or ALCOHOLIC DRINK$ or ALCOHOL).ti.
12.	(DIET$ or FOOD$ or EAT or EATEN or EATING or NUTRITION$ or FRUIT$ or VEGETABLE$ or NUTRIENT$ or VITAMIN C or THIAMIN or NIACIN or FOLATE$ or MICRONUTRIENT$ or MACRONUTRIENT$ or MULTIVITAMIN$ or FOOD SAFETY or SUPPLEMENT$ or FISH OIL or PROBIOTIC$ or PREBIOTICS$ or FOOD GROUP$ or DIET$ QUALITY or DIET$ PATTERN$ or FOLIC ACID or MAGNESIUM or SELENIUM or ZINC or PYRIDOXINE or RIBOFLAVIN or NICOTINIC ACID or DIETARY SALT or ALCOHOLIC DRINK$ or ALCOHOL).ab.
13.	DIET/ or exp FOOD/ or NUTRITION/ or exp FRUIT/ or exp VEGETABLES/ or DIETARY IRON/ or DIETARY CALCIUM/ or exp DIETARY FATS/ or exp DIETARY PROTEINS/ or DIETARY CARBOHYDRATES/ or exp VITAMINS/ or exp RIBOFLAVIN/ or exp NICOTINIC ACIDS/ or PYRIDOXINE/ or ZINC/ or FOLIC ACID/ or MAGNESIUM/ or SELENIUM/ or SODIUM, DIETARY/ or exp ENERGY INTAKE/
14.	11 or 12 or 13
15.	10 and 14
16.	exp ANIMALS/ not HUMANS.sh.
17.	15 not 16
18.	exp ASIA/ or exp AFRICA/ or exp SOUTH AMERICA/ or exp DEVELOPING COUNTRIES/
19.	17 not 18
20.	exp PRACTICE GUIDELINES/
21.	HEALTH PLANNING GUIDELINES/
22.	GUIDELINE$.ti.
23.	(PRACTICE adj3 PARAMETER$).ti,ab.
24.	CLINICAL PROTOCOLS/
25.	GUIDANCE.ti,ab.
26.	CARE PATHWAY$.ti,ab.
27.	CRITICAL PATHWAY/
28.	(CLINICAL adj3 PATHWAY$).ti,ab.
29.	CONSENSUS DEVELOPMENT CONFERENCE.pt.
30.	CONSENSUS DEVELOPMENT CONFERENCE NIH.pt.
31.	(((comprehensive* or systematic*) adj3 (bibliographic* or review* or literature)) or (meta-analy* or metaanaly* or “research synthesis” or ((information or data) adj3 synthesis) or (data adj2 extract*))).ti,ab. or ((cochrane adj3 trial*) or “web of science”).ab. or “cochrane database of systematic reviews”.jn. or ((review adj5 (rationale or evidence)).ti,ab. and review.pt.) or meta-analysis as topic/ or Meta-Analysis.pt.
32.	(“clinical trial” or “clinical trial, phase i” or “clinical trial, phase ii” or clinical trial, phase iii or clinical trial, phase iv or controlled clinical trial or “multicenter study” or “randomized controlled trial”).pt. or double-blind method/ or clinical trials as topic/ or clinical trials, phase i as topic/ or clinical trials, phase ii as topic/ or clinical trials, phase iii as topic/ or clinical trials, phase iv as topic/ or controlled clinical trials as topic/ or randomized controlled trials as topic/ or early termination of clinical trials as topic/ or multicenter studies as topic/ or ((randomi?ed adj7 trial*) or (controlled adj3 trial*) or (clinical adj2 trial*) or ((single or doubl* or tripl* or treb*) and (blind* or mask*))).ti,ab.
33.	20 or 21 or 22 or 23 or 24 or 25 or 26 or 27 or 28 or 29 or 30 or 31 or 32
34.	19 and 33
35.	limit 34 to yr = “2010 -Current”

Figure 1. Flowchart of study selection process. ¹No access to this database outside Great-Britain. ²Duplicates within one database or at one website were identified and excluded from the number of screened records, duplicates between databases or websites were not.

Table 3. Summary description of documents included.

Reference	Included in	Study Design	Year	Moment of Intervention	EarlyNutrition Infant outcome
VITAMIN D
Czech-Kowalska et al. (Czech-Kowalska et al., 2014)	—	RCT	2014	– Lactation (3 wks pp)	Overweight/obesity
SYNBIOTICS/PROBIOTICS
Ostadrahimi et al. (Ostadrahimi et al., 2013)	—	RCT	2013	– Lactation	Overweight/obesity Metabolic syndrome
Aaltonen et al. (Aaltonen et al., 2011)	—	RCT	2011	– Pregnancy (1st and 3rd trimester)	Overweight/obesity
				– Lactation (6 mo pp)
LC-PUFA
Campoy et al. (Campoy et al., 2012)	—	Systematic review	2012	– Pregnancy	Overweight/obesity
				– Lactation
				– Both
Koletzko et al. (Koletzko et al., 2014a)	—	Systematic review	2014	– Pregnancy	Overweight/obesity
				– Lactation	Hypertension
				– Both
Martínez-Victoria et al. (Martinez-Victoria and Yago 2012)	—	Systematic review	2012	– Pregnancy	Overweight/obesity
				– Lactation
				– Both
Stratakis et al. (Stratakis et al., 2014)	—	Systematic review	2014	– Pregnancy	Overweight/obesity
				– Lactation
				– Both
Muhlhausler et al. (Muhlhausler et al., 2010)	—	Systematic review	2010	– Lactation	Overweight/obesity
				– Both
Rodriguez et al. (Rodriguez et al., 2012)	—	Systematic review	2012	– Both pregnancy and lactation	Overweight/obesity
				– Lactation only
Delgado et al. (Delgado-Noguera et al., 2015)	—	Cochrane review	2015	– Both pregnancy and lactation	Overweight/obesity
				– Lactation only
RCTs included in systematic reviews on LC-PUFAs, and describing (one of) our outcomes: published 2010-onwards
Hauner et al. (Hauner et al., 2012)	Delgado	RCT	2012	– Both pregnancy and lactation (15 w PCA–4 mo pp)	Overweight/obesity
	Koletzko
	Rodriguez
Bergmann RL et al. (Bergmann et al., 2012)	Delgado	RCT	2012	– Pregnancy (21 w–37 wks PCA)	Overweight/obesity
	Stratakis			– Lactation (delivery–3 mo pp)
Jensen et al. (Jensen et al., 2010)	Campoy	RCT	2010	– Lactation (5 days–4 mo pp)	Overweight/obesity
	Delgado
RCTs included in systematic reviews on LC-PUFAs, and describing (one of) our outcomes: published before 2010
Asserhoj et al. (Asserhoj et al., 2009)	Delgad	RCT	2009	– Lactation (2 w–4 mo pp)	Overweight/obesity
	Muhlhauser				Hypertension
	Koletzko
	Rodriguez
	Stratakis
Helland et al. (Helland et al., 2008)	Campoy	RCT	2008	– Both pregnancy and lactation (18 w PCA–3 mo pp)	Overweight/obesity
	Delgado
	Koletzko
	Muhlhauser
	Rodriguez
	Stratakis
Lucia Bergmann et al. (Lucia Bergmann et al., 2007)	Campoy	RCT	2007	– Pregnancy (21 w–37 w PCA)	Overweight/obesity
	Delgado			– Lactation (after delivery 3 mo pp)
	Martínez-
	Victoria
	Muhlhauser
	Rodriguez
	Stratakis
Lauritzen et al. (Lauritzen et al., 2005)	Delgado	RCT	2005	– Lactation (2 w–4 mo pp)	Overweight/obesity
	Martínez-Victoria
	Muhlhauser
	Rodriguez Stratakis
Jensen et al. (Jensen et al., 2005)	Campoy	RCT	2005	– Lactation (5 days–4 mo pp)	Overweight/obesity
	Delgado
Ulbak et al. (Ulbak et al., 2004)	Delgado	RCT	2004	– Lactation (2 w–4 mo pp)	Hypertension
Helland et al. (Helland et al., 2001)	Campoy	RCT	2001	– Both pregnancy and lactation (18 w PCA–3 mo pp)	Overweight/obesity
	Delgado
	Martínez-Victoria

LC-PUFA; long chain- polyunsaturated fatty acid. PCA; post-conceptual age. PP; postpartum. DHA; docohexaenoic acid. EPA; eicosapentaenoic acid. GA; Gestational age. FOS; Fructo-oligosaccharide. W; weeks. Mo; months. y; years. BMI; body mass index. HC; head circumference.

Table 4. Dietary recommendations in excluded documents.

REFERENCE	RECOMMENDATION
MACRONUTRIENTS & OVERALL ENERGY INTAKE
EFSA 2013	For exclusive breastfeeding during the first six months of life, the mean energy expenditure of lactation over this period is 2.8 MJ/day (670 kcal/day) based on a mean milk production of 807 g/day, an energy density of milk of 2.8 kJ/g (0.67 kcal/g), and an energetic efficiency of 80%. Energy mobilization from tissues in the order of 0.72 MJ/day (170 kcal/day) may contribute to this energy expenditure and reduce the additional energy requirement during lactation to 2.1 MJ/day (500 kcal/day) over pre-pregnancy requirements.
Scientific Opinion on Dietary Reference Values for energy
EFSA 2010	Adequate intake of water for females is 2.0 L/day (P95: 3.1 L).
Scientific Opinion on Dietary Reference Values for water	Adequate intake for lactating women is approximately 700 mL/day higher.
Australian dietary guidelines 2013	Minimum recommended intake for lactating women are
	> 7 serves/day of vegetables
	2 serves/day of fruit
	8½ serves/day of grain/cereal (2 slices of bread = 2 serves.)
	2½ serves/day for milk, yoghurt, cheese and/or alternatives
	2½ serves/day for lean meats and poultry, fish, eggs, tofu, nuts and seeds, and legumes/beans
	For women who are lactating, not drinking alcohol is the safest option.
WHO 2013	Women in the postnatal period need to maintain a balanced diet.
Counseling for maternal and newborn health care	Iron and folic acid supplementation should also continue for 3 months after birth.
A handbook for building skills	Women who are breastfeeding require additional food and should drink sufficientclean water.
Australia and New Zealand, Early-Life Nutrition, Working Party 2014	Typically, a breastfeeding woman needs an additional 2,000–2,100kj per day over the recommended daily intake for women.
	The energy intake of a breastfeeding woman would be at least 20% fat – any less may affect the fat content of your milk.
Nurturing future health through nutrition
	Ensure an adequate intake of iodine (150mg daily) and other important vitamins and minerals.
	In case of a vegan, vegetarian, or other restrictive diet, there may be a greater risk for nutrient deficiencies. Consideration of seeing a dietitian to ensure the diet is nutritionally balanced to meet the needs of breastfeeding is needed.
EFSA 2012	For lactation a protein intake of 19 g/day during the first six months, and 13 g/day after six months is recommended.
Scientific Opinion on Dietary Reference Values for protein
EFSA 2012	Available data are insufficient to establish an upper limit for n-3 LC-PUFA (individually or combined) for any population group.
Scientific Opinion on the Tolerable Upper Intake Level of EPA, DHA and DPA1
EFSA 2010	The Panel proposes to set an adequate intake of 250 mg for eicosapentaenoic acid (EPA) plus docosahexaenoic acid (DHA) for adults based on cardiovascular considerations. To this intake 100 to 200 mg of preformed DHA should be added during lactation to compensate for oxidative losses of maternal dietary DHA and accumulation of DHA in body fat of the infant.
Scientific Opinion on Dietary Reference Values for fats
Dietary Guidelines for Americans 2010	For lactating women consuming 8–12 ounces/week of seafood from a variety of seafood types is associated with improved infant health outcomes, such as visual and cognitive development.
	Lactating women should limit white (albacore) tuna to 6 ounces/week and should not eat tilefish, shark, swordfish, and king mackerel, due to their high methyl mercury content.
	Lactating women should be very cautious about drinking alcohol, if they choose to drink at all.
NGC 2010	Women who are breastfeeding should consume 8 to 12 ounces of seafood per week from a variety of seafood types. Due to their high methyl mercury content, lactating women should limit white (albacore) tuna to 6 ounces per week and should not eat the following four types of fish: tilefish, shark, swordfish, and king mackerel.
NGC-8567
	They should maintain appropriate calorie balance to maintain weight during breastfeeding.
MICRONUTRIENTS: GENERAL ADVICE
SACN 2011	There are increased requirements for a number of nutrients for lactation.
Early-Life Nutrition Report	These include referent nutrient intakes set for the provision of energy (for different stages of lactation), protein, folate, vitamin A, vitamin D, vitamin C, B vitamins (thiamin, riboflavin, niacin, vitamin B12) and also for a number of minerals (calcium, phosphorus, magnesium, zinc, copper and selenium) [Department of Health, 1991]. Current advice is that all of these intakes can be achieved through a varied and balanced diet, apart from vitamin D, which requires a 10 µg daily supplement for the duration of breastfeeding in order to ensure the requirement is met.
WHO 2013	Recommended composition of multiple micronutrient supplements for lactating women, designed to provide the daily recommended intake of each nutrient (one RNI): Vitamin A 800 μg, Vitamin D 5 μg, Vitamin E 15 mg, Vitamin C 55 mg, Thiamine (vitamin B1) 1.4 mg, Riboflavin (vitamin B2) 1.4 mg, Niacin (vitamin B3) 18.0 mg, Vitamin B6 1.9 mg, Vitamin B12 2.6 μg, Folic acid 600 μg, Iron 27.0 mg, Zinc 10 mg, Copper 1.15 mg, Selenium 30 μg, Iodine 250 μg
Essential Nutrition Actions: Improving Maternal, Newborn, Infant and Young Child Health and Nutrition.
	Lactating women should be given this supplement providing one reference nutrition intake (RNI) of micronutrients daily, whether they receive fortified rations or not. Iron and folic acid supplements, when already provided, should be continued.
CALCIUM
EFSA 2012	The upper limit for calcium for all adults, including lactating women is 2,500 mg. This upper limit was based on different long-term intervention studies in which a total daily intake of 2,500 mg of calcium/day from all sources (diet and supplements) was tolerated without adverse effects.
Scientific Opinion on the Tolerable Upper Intake Level of calcium
FOLATE
EFSA 2014	The Panel notes that the average folate concentration of breast milk is 80 μg/L (about 180 nmol/L) and that this amount is not dependent on dietary folate intake or status of the lactating women.
Scientific Opinion on Dietary Reference Values for folate
	The Panel considers that lactating women have increased folate requirements compared with non-lactating women to compensate for folate losses through their milk. A lactating woman would require 128 μg/day of additional folate to compensate for her losses. A value of 130 μg/day is added to the average requirement for non-lactating women, resulting in an average requirement of 380 μg DFE/day, with a population reference intake of 500 μg DFE/day.
IODINE
NHMRC public statement 2010	The National Health and Medical Research Council (NHMRC) recommends that all women who are breastfeeding take an iodine supplement of 150 μg each day.
Iodine Supplementation for Pregnant and Breastfeeding Women
	Women with pre-existing thyroid conditions should seek advice from their medical practitioner prior to taking a supplement.
WHO 2013	WHO and UNICEF recommend iodine supplementation (240 μg/day or 400mg/year) for lactating women in countries where less than 20% of households have access to iodized salt, until the salt iodization program is scaled up.
Essential Nutrition Actions: Improving Maternal, Newborn, Infant and Young Child Health and Nutrition.
WHO 2014	It is recommended that lactating women consume 250 µg of iodine per day.
Fortification of food-grade salt with iodine for the prevention and control of iodine deficiency disorders
EFSA 2014	Iodine concentrations in breast milk of European women vary widely and large iodine stores exist in conditions of adequate iodine status before lactation. The Panel therefore considered that a full compensation for the iodine secreted in breast milk may not be justified for the derivation of dietary reference values for iodine for lactating women. Therefore, for lactating women the same adequate intake is proposed as for pregnant women, i.e. 200 µg/day.
Scientific Opinion on Dietary Reference Values for iodine
VITAMIN A
Gogia S. et al 2011	There is no convincing evidence that maternal vitamin A supplementation (both <200.000IU/day and ≥200.000IU/day) during lactation results in a reduction in infant mortality or morbidity in low and middle income countries.
(PMID 21975770)
WHO 2011	Vitamin A supplementation in postpartum women is not recommended for the prevention of maternal and infant morbidity and mortality.
Guideline: Vitamin A Supplementation in Postpartum Women
EFSA 2015	Vitamin A population reference intakes for women are 650 µg retinol equivalent/day.
Scientific Opinion on Dietary Reference Values for vitamin A
	For lactation, additional vitamin A requirements of 1300 µg retinol equivalent/day are recommended, related to transfer of retinol into breast milk.
VITAMIN C
EFSA 2013	Lactating women secrete vitamin C via breast milk. Vitamin C concentration in human milk reflects maternal vitamin C intake more than the infants' requirement (WHO/FAO, 2004). The Panel notes that mean vitamin C concentration of human milk from healthy mothers not taking vitamin C supplements is in the range of 35–90 mg/L.
Scientific Opinion on Dietary Reference Values for vitamin C
	For lactating women 60 mg/day in addition to the population reference intake of 95 mg/day of non-lactating women are proposed.
VITAMIN D
EFSA 2012	The upper limit of vitamin D for all adults, including lactating women is 100 µg/day.
Scientific Opinion on the Tolerable Upper Intake Level of vitamin D
NICE 2014	Population groups at higher risk of having a low vitamin D status including all breastfeeding women, particularly teenagers and young women, are currently advised to take a supplement that meets 100% of the reference nutrient intake for their age group. This is 10 μg/day (400 IU) for adults.
NICE guidelines [PH56]
NICE public health guidance 11, 2014	In 1991, Committee on Medical Aspects of Food and Nutrition Policy set a reference nutrient intake (RNI) of 10 μg of vitamin D per day for all pregnant and breastfeeding women.
Maternal and child nutrition
	In 2007, the Scientific Advisory Committee on Nutrition confirmed that these recommendations should remain unchanged.
Public Health England 2014	Lactating women should take a vitamin D supplement (10 µg/day) to ensure they get enough vitamin D.
Vitamin D: for healthcare professionals and the public
NGC 2011	Midwives should offer every woman information and advice on the benefits of taking a vitamin D supplement (10 µg/day) while breastfeeding.
NGC-6418
	They should explain that it will increase both the mother's and her baby's vitamin D stores and reduce the baby's risk of developing rickets.
SIGN 2010	It is recommended that breastfeeding mothers take a supplement containing 10 µg vitamin D.
Management of obesity
IoM 2011	There is no evidence that calcium requirements are different for lactating females compared with non-lactating counterparts, since post-lactation maternal bone mineral is restored without consistent evidence that higher calcium intake is required. The estimated average requirement for calcium for non-lactating women and adolescents are applicable, which are 800 mg/day and 1,100 mg/day respectively.
	Increased maternal vitamin D intakes increase maternal serum 25OHD levels, with no effect on the neonatal serum 25OHD levels of breastfed infants unless the maternal intake of vitamin D is extremely high (i.e., 4,000 to 6,400 IU/day). Observational studies report no relationship between maternal serum 25OHD levels and bone mass density. There is no evidence that lactating adolescents require any more vitamin D or higher serum 25OHD levels than non-lactating adolescents. The estimated average requirement is thus 400 IU/day of vitamin D for lactating women and adolescents.
	Available data do not indicate a basis for deriving upper limits for calcium and vitamin D for lactating women that are different from those for their non-lactating counterparts (2,500 mg/day calcium and 4,000 IU (100 μg)/day vitamin D)
Dietary Reference Intakes for Calcium and Vitamin
Oberhelman et al. 2013	Either single dose (150000IU) or daily maternal cholecalciferol (5000IU) can provide breast milk concentrations that result in vitamin D sufficiency in their infants.
PMID 3923377
	Larger trials demonstrating the safety of cholecalciferol supplementation in lactating mothers need to be conducted before universally adopting this strategy for preventing infant vitamin D deficiency.
VITAMIN K
eMedicine.com 2014	The adequate intake for vitamin K for lactating women is 90 mcg/day. These recommendations only fulfill the requirement for coagulation function.
Vitamin K Deficiency (Treatment)
SODIUM
WHO 2012	WHO recommends a reduction in sodium intake to reduce blood pressure and risk of cardiovascular disease, stroke and coronary heart disease in adults to <2 g/day sodium (5 g/day salt) in adults (strong recommendation).
Sodium intake for adults and children
	This recommendation applies to all individuals, with or without hypertension, including lactating women.
ZINC
EFSA 2014	The population reference intake for zinc for adult women is 7.5–12.7 mg/day. This is derived from zinc requirement of individuals with a body weight at the 97.5th percentile for reference weights for women.
Scientific Opinion on Dietary Reference Values for zinc
	During lactation, zinc requirements are an additional 2.9 mg/day, related to transfer into breast milk.
OTHER
EFSA 2014	Adequate intake for adults: 40 µg/day. For lactating women, an additional 5 µg/day, is recommended to compensate for biotin losses through breast milk. Mean concentrations of biotin in mature human milk measured by microbiological assays typically range between about 4 and 6 µg/L.
Scientific Opinion on Dietary Reference Values for biotin
EFSA 2014	The Panel concludes that no average requirement and no population reference intake for chromium can be defined, that there is no evidence of beneficial effects associated with chromium intake in healthy subjects, and that the setting of an adequate intake for chromium is also not appropriate
Scientific Opinion on Dietary Reference Values for chromium
EFSA 2013	The adequate intake of fluoride from all sources (including non-dietary sources for both children and adults, including lactating women is 0.05 mg/kg/day.
Scientific Opinion on Dietary Reference Values for fluoride
EFSA 2013	The adequate intake of manganese for all adults, including lactating women is 3 mg/day.
Scientific Opinion on Dietary Reference Values for manganese
EFSA 2013	The adequate intake of molybdenum for all adults, including lactating women is 65 µg/day.
Scientific Opinion on Dietary Reference Values for molybdenum
EFSA 2014	The average requirement for niacin for all adults, including lactating women is 1.3 mg NE/MJ (5.5 mg NE/1 000 kcal, which is adopted by the Scientific Committee for Food.
Scientific Opinion on Dietary Reference Values for niacin
EFSA 2014	The adequate intake for lactating women is 7 mg/day, to compensate for pantothenic acid losses through breast milk.
Scientific Opinion on Dietary Reference Values for pantothenic acid
EFSA 2014	An adequate intake of 70 μg/day for adults was set. Based on an average amount of selenium secreted in breast milk of 12 μg/day and an absorption efficiency of 70% from usual diets, an additional selenium intake of 15 μg/day was considered to replace these losses. Thus, an adequate intake of 85 μg/day is proposed for lactating women.
Scientific Opinion on Dietary Reference Values for selenium

Table 5. Documents on LC-PUFA supplementation during lactation—summary of study results.

Parameter		In reference	Time-point	Individual conclusion	Conclusion in meta-analysis Delgado	Meta-analysis based on
Weight:	Short-term	Helland et al., 2001	6 w, 3, 6, 9 & 2 mo	No difference	LC-PUFA supplementation: significant higher weight	Helland et al.
		Jensen et al., 2005	3 w, 2, 4, 8, 12 mo	No difference		Lauritzen et al.
		Lauritzen et al., 2005	2, 4 & 9 mo	No difference		Hauner et al.
		Hauner et al., 2012	6 w, 4 & 12 mo	No difference
	Medium-term	Jensen et al., 2005	18 & 24 mo	No difference	LC-PUFA supplementation: significant lower weight	Lucia Bergmann et al.
		Lucia Bergmann et al., 2007	21 mo	LC-PUFA supplementation: significant lower weight
	Long-term	Jensen et al., 2010	30 mo	No difference	No difference	Helland et al.
		Lauritzen et al., 2005	2.5 y	No difference		Jensen et al.
		Helland et al., 2008	7 y	No difference		Asserhoj et al.
		Asserhoj et al., 2009	7 y	No difference		Bergmann et al.
		Bergmann et al., 2012	6 y	No difference
		Jensen et al., 2010	5 y	No difference
BMI:	Short-term	Lauritzen et al., 2005	2, 4 & 9 mo	No difference	No difference	Hauner et al.
		Lucia Bergmann et al., 2007	1 & 3 mo	No difference
		Hauner et al., 2012	6 w, 4 & 12 mo	No difference
	Medium-term	Lucia Bergmann et al., 2007	21 mo	LC-PUFA	-“no studies reported on this outcome”	—
				supplementation: significant lower weight	No difference	Bergmann et al.
	Long-term	Lauritzen et al., 2005	2.5 y	LC-PUFA supplementation: significant higher BMI
		Helland et al., 2008	7 y	No difference
		Asserhoj et al., 2009	7 y	No difference
		Bergmann et al., 2012	6 y	No difference
Fat mass & Fat distribution:	Short-term	Hauner et al., 2012	6 w, 4 & 12 mo	No difference	No difference	Hauner et al.
	Medium-term	None
	Long-term	Lauritzen et al., 2005	2.5 y	No difference	No difference	Bergmann et al.
		Helland et al., 2008	7 y	No difference
		Asserhoj et al., 2009	6 y	No difference
		Bergmann et al., 2012	7 y	No difference

LC-PUFA; Long chain-polyunsaturated fatty acids. W; weeks. Mo; months. Y; years. BMI; body mass index.

Table 6. Research gaps identified by the authors of documents included.

Reference	Further research / research gaps (if identified by the authors)	Notes/ Type of intervention discussed
Czech-Kowalska et al.	Range of optimal 25(OH)D level in mothers	Vitamin D supplementation during lactation in women and infants
	– Amount of vitamin D during lactation to reach and maintain optimal 25(OH)D levels in mothers
	– Intervention study needed with higher vitamin D supplementation doses (1500IU/d vs. 2000IU/d vs.
	3000 IU/d) in mothers
Ostadrahimi et al.	– Pilot study in the field, therefore further studies (in undernourished mothers) are needed	Synbiotic supplementation in lactating women
Aaltonen et al.	– Independent effect of maternal probiotic supplementation during lactation on infants' 32–33 high split proinsulin	Maternal dietary counseling, probiotic supplementation during pregnancy and lactation
Rodriquez et al.	– Mechanisms on the potential relationship between maternal n-3 LC-PUFA intake and infant growth or later body composition	n-3 LC-PUFA supplementation in lactating women
Muhlhauser et al.	– Sufficiently powered studies, with appropriate controls, adequate blinding of participants and investigators, and high retention rates.	n-3 LC-PUFA supplementation in (pregnant &) lactating women
Koletzko et al.	– Control for baseline nutritional status and intakes, as well as genetic variation (e.g. the FADS genotype)	n-3 LC-PUFA supplementation in (pregnant &) lactating women
Martinez-Victoria et al.	– Randomized controlled trials with harmonized variables	n-3 LC-PUFA supplementation in (pregnant &) lactating women
Stratakis et al.	– High-quality trials are needed to establish whether n-3 LCPUFA supplementation in the perinatal period affects adiposity in children	n-3 LC-PUFA supplementation in (pregnant &) lactating women
	– Appropriate control regimen
	– Further explorement of sources of heterogeneity and effect modification
Campoy et al.	– Comparable results	n-3 LC-PUFA supplementation in (pregnant &) lactating women
	– Analysis of FADS gene
Delgado et al.	– Standardization of techniques for measurements of different outcomes	n-3 LC-PUFA supplementation in lactating women
Hauner et al.	—	n-3 LC-PUFA supplementation and a reduced n6 LC-PUFA intake in (pregnant &) lactating women.
Bergmann et al.	– Large studies with long observation periods, combined with genetic tests.	n-3 LC-PUFA supplementation in (pregnant &) lactating women.
	– Comparable study designs
Jensen et al.	– Mechanisms underlying long-term benefits of early nutritional interventions	n-3 LC-PUFA supplementation in lactating women.

Czech-Kowalska, J., Latka-Grot, J., Bulsiewicz, D., Jaworski, M., Pludowski, P., Wygledowska, G., Chazan, B., Pawlus, B., Zochowska, A., Borszewska-Kornacka, M. K., Karczmarewicz, E., Czekuc-Kryskiewicz, E. and Dobrzanska, A. (2014). Impact of vitamin D supplementation during lactation on vitamin D status and body composition of mother-infant pairs: A MAVID randomized controlled trial. PLoS One 9(9):e107708.

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Ostadrahimi, A., Nikniaz, L., Mahdavi, R., Hejazi, M. A. and Nikniaz, Z. (2013). Effects of synbiotic supplementation on lactating mothers' energy intake and BMI, and infants' growth. Int. J. Food Sci. Nutr. 64(6):711–714.

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Aaltonen, J., Ojala, T., Laitinen, K., Poussa, T., Ozanne, S. and Isolauri, E. (2011). Impact of maternal diet during pregnancy and breastfeeding on infant metabolic programming: A prospective randomized controlled study. Eur. J. Clin. Nutr. 65(1):10–19.

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Campoy, C., Escolano-Margarit, M. V., Anjos, T., Szajewska, H. and Uauy, R. (2012). Omega 3 fatty acids on child growth, visual acuity and neurodevelopment. Br. J. Nutr. 107(Suppl 2):S85–S106.

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Martinez-Victoria, E. and Yago, M. D. (2012). Omega 3 polyunsaturated fatty acids and body weight. Br. J. Nutr. 107(Suppl 2):S107–S116.

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